Cardiology · ESC

Acute coronary syndrome

ESC

Source:2023 ESC Guidelines for the management of acute coronary syndromes

Verified Apr 2026

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Red Flags

ST elevation ≥1 mm in 2 contiguous leads or new LBBB — immediate reperfusion (FMC-to-device ≤90 min direct, ≤120 min if transfer)^[2]
Cardiogenic shock complicating ACS — emergent PCI of culprit only; mechanical support if SCAI C/D/E^[2]
Out-of-hospital cardiac arrest with ROSC and STEMI on ECG — immediate cath lab; routine CT before angiography NOT recommended unless suspected non-coronary cause^[2]
Very-high-risk NSTE-ACS (haemodynamic instability, refractory ischaemia, life-threatening arrhythmia, mechanical complication) — immediate invasive (<2 h)^[2]

First-line treatment

Interventions

Primary PCI (preferred for STEMI)^[2]
FMC-to-device ≤90 min direct, ≤120 min if transfer; complete revascularisation during index admission preferred
DAPT duration^[2]
Default 12 months DAPT post-ACS; shorten to 1–6 months in high bleeding risk (HBR) per ARC-HBR; extend with low-dose ticagrelor or rivaroxaban 2.5 mg BD in selected high-ischaemic-risk patients

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Aspirin^[2]	Antiplatelet (loading)	150–300 mg chewed at FMC then 75–100 mg daily	—	All ACS unless contraindicated
Prasugrel or ticagrelor^[2]	P2Y12 inhibitor	Prasugrel 60 mg load then 10 mg daily; ticagrelor 180 mg load then 90 mg BD	—	Prasugrel preferred over ticagrelor in PCI-treated NSTE-ACS where coronary anatomy known (ISAR-REACT 5)
Atorvastatin^[2]	High-intensity statin	40–80 mg PO daily started in hospital	—	Add ezetimibe early per 2023 update for combination LDL-C lowering
Bisoprolol or carvedilol^[2]	Beta-blocker	Bisoprolol 1.25–10 mg daily; carvedilol 3.125–25 mg BD; titrate post-stabilisation	—	Within 24 h if no contraindication
Ramipril or perindopril^[2]	ACE inhibitor	Ramipril 1.25–5 mg BD; perindopril 4–8 mg daily	—	All ACS within 24 h, especially anterior MI, LVEF <40%, HF, diabetes, CKD
Unfractionated heparin or enoxaparin^[2]	Parenteral anticoagulant	UFH 70–100 U/kg IV bolus during PCI; enoxaparin 1 mg/kg SC BD	—	Bivalirudin alternative; reduce enoxaparin if eGFR 15–30; UFH if eGFR <15

Aspirin^[2]

Antiplatelet (loading)

Adult: 150–300 mg chewed at FMC then 75–100 mg daily
Paediatric: —

All ACS unless contraindicated

Prasugrel or ticagrelor^[2]

P2Y12 inhibitor

Adult: Prasugrel 60 mg load then 10 mg daily; ticagrelor 180 mg load then 90 mg BD
Paediatric: —

Prasugrel preferred over ticagrelor in PCI-treated NSTE-ACS where coronary anatomy known (ISAR-REACT 5)

Atorvastatin^[2]

High-intensity statin

Adult: 40–80 mg PO daily started in hospital
Paediatric: —

Add ezetimibe early per 2023 update for combination LDL-C lowering

Bisoprolol or carvedilol^[2]

Beta-blocker

Adult: Bisoprolol 1.25–10 mg daily; carvedilol 3.125–25 mg BD; titrate post-stabilisation
Paediatric: —

Within 24 h if no contraindication

Ramipril or perindopril^[2]

ACE inhibitor

Adult: Ramipril 1.25–5 mg BD; perindopril 4–8 mg daily
Paediatric: —

All ACS within 24 h, especially anterior MI, LVEF <40%, HF, diabetes, CKD

Unfractionated heparin or enoxaparin^[2]

Parenteral anticoagulant

Adult: UFH 70–100 U/kg IV bolus during PCI; enoxaparin 1 mg/kg SC BD
Paediatric: —

Bivalirudin alternative; reduce enoxaparin if eGFR 15–30; UFH if eGFR <15

Safety-net

Take dual antiplatelet therapy every day for 12 months without interruption — stopping early sharply raises stent-thrombosis risk^[2]
New chest pain after discharge — call emergency services immediately^[2]
Attend cardiac rehabilitation — supervised exercise reduces death and re-admission by 20–30%^[2]

Referral criteria

STEMI ECG diagnosticActivate cath lab; transfer to PCI-capable centre if not on-site^[2]
Cardiogenic shock or mechanical complicationHeart team; mechanical circulatory support consideration^[2]
Very-high-risk NSTE-ACSEmergency angiography <2 h^[2]
Post-ACS LVEF ≤35% at 40 days despite optimal therapyCardiology for ICD evaluation^[2]

Clinical summary

European-perspective diagnosis, reperfusion, and post-ACS management combining STEMI and NSTE-ACS into a single framework.

References

1.2023 ESC Guidelines for the management of acute coronary syndromes (2023)
2.2023 ESC Guidelines for the management of acute coronary syndromes. European Heart Journal (2023)

Drug

Class

Adult

Paediatric

Notes